Primary microsurgical repair of ring avulsion amputation injuries

Patients with ring avulsion injuries of the fourth and fifth digits often demand attempts at reconstruction rather than completion of the amputation. In the past, this has led to reconstruction involving a staged series of operations with results that were often less than desirable. Seven patients with ring avulsion amputation injuries that were reconstructed by use of microsurgical reanastomoses are reported. All were classified as either Carroll type IV or Urbaniak type III. Six patients (85%) had a successful replantation leading to a useful finger. The operating time averaged 5.5 hours. On average, 1.9 arteries (range 1 to 2) and 3.3 veins (range 2 to 5) were repaired for each digit. Average hospital stay was 6.7 days (range 4 to 15). Average range of motion was 0(2)/84(2) for metacarpophalangeal joint and 15(2)/90(2) for proximal interphalangeal joint (PIP) with distal interphalangeal joint ankylosis at between 0(2) and 15(2) of flexion. Sensibility was protective in all cases and good in three. If the PIP joint was damaged, completion of amputation was the treatment of choice. If the amputation is distal to the PIP with a functional superficialis tendon, primary microsurgical repair is the treatment of choice in complex ring avulsion injuries.     

手指戒指撕脱性损伤的显微修复

目的探讨显微修复手指戒指撕脱性损伤的方法与疗效。方法2009年3月至2014年12月,急诊收治手指戒指撕脱性损伤患者6例6指,其中男4例,女2例;年龄18~30岁,平均22岁;环指4例,中指2例,损伤平面均在掌指横纹,伴有指骨间关节骨折脱位的予复位固定,修复损伤韧带及掌板、伸肌腱,吻合动、静脉,缝合指神经,术后系统康复锻炼。结果6指全部成活,随访8~30个月,手指外形良好,近侧指骨间关节主动活动范围70°~100°,平均80°,远侧指骨间关节主动活动范围40°~60°,平均50°,感觉恢复至S3~S3+,指腹两点辨别觉为5~12mm。按中华医学会手外科学会断指再植功能评定试用标准评定:优4指,良2指。结论通过显微外科技术修复手指戒指撕脱性损伤,术后系统康复锻炼,疗效满意。     

Analysis of prognostic factors in ring avulsion injuries

PURPOSE: To report 105 cases of ring avulsion injuries, examine the factors affecting rate of survival and functional outcome after reconstruction, and evaluate whether these data provide enough evidence to support attempts to repair these injuries. METHODS: A retrospective cohort study was conducted in 105 patients with 105 ring avulsion injuries of all grades of severity treated at our center between 1977 and 2003. Factors that could affect the outcome included personal (gender, age, smoking history, vascular disease, diabetes mellitus, alcohol abuse), injury (finger affected, level of skeletal injury, presence of tendon and nerve injury, Urbaniak class as modified by Kay et al, presurgery time), and surgery features (number of arteries and veins reconstructed primarily and with vein grafts). Results were interpreted based on survival and final function. Function was measured by the presence of pain, range of motion, and 2-point discrimination. RESULTS: Of the 86 digits with inadequate circulation, 11 digits had primary amputation. Reconstruction was attempted in 75 digits. Fourteen digits had secondary amputation because of revascularization failure. Failure was attributed to artery problems in 5 digits and to vein problems in 5 digits and was unknown in 4 digits. The overall survival rate was 81%. CONCLUSIONS: Cigarette smoking is not associated with higher risk of revascularization failure. Reconstruction of 2 or more veins resulted in higher survival rates compared with reconstruction of only 1 vein. Level of bone injury is not an accurate indication of whether to attempt reconstruction. Primary nerve repair does not lead to a good sensory recovery in most digits. Patients who had their digits finally amputated had variable periods of hypersensitivity at the stump, which prolonged their convalescence time.     

Long-term functional outcomes of all-inside arthroscopic repair of anterior talofibular ligament avulsion fracture

BackgroundThe main purpose of this study was to describe the all-inside arthroscopic technique for repairing anterior talofibular ligament (ATFL) avulsion fractures at the attachment points of the fibula and talus, and to evaluate the functional outcomes during long-term follow-up.MethodsThe data of 78 patients with ATFL avulsion fracture treated in our hospital from August 2013 to November 2016 were analyzed retrospectively. All patients underwent surgery. Patients were divided into two groups according to whether they had undergone all-inside arthroscopic treatment or open treatment. The American Orthopedic Foot and Ankle Society (AOFAS) score, Karlsson Ankle Functional Score (KAFS), Foot and Ankle Outcome Score (FAOS) and a 36-item Short Form Health Survey questionnaire (SF-36) were used to evaluate functional outcomes.ResultsThe postoperative follow-up period was 24–48 months. All patients reported subjective improvements to ankle stability without any nerve, blood vessel or tendon complications. At the final follow-up, there was no significant difference in the AOFAS, SF-36 or sport participation rate between the arthroscopic group and the open group; however, the KAFS and FAOS were significantly higher in the arthroscopic group than in the open group.ConclusionsFor ATFL avulsion fractures, the all-inside ankle arthroscopic procedure produced better outcomes than did the open procedure. The all-inside ankle arthroscopic procedure provides a minimally invasive technique with acceptable long-term functional outcomes.     

An experimental study of ring avulsion injuries and two preventive devices

We have performed biomechanical experiments on fresh cadaveric fingers to test two modifications to normal rings which may prevent ring avulsion injuries. One of these modifications produced reliable protection against ring avulsion accidents and was undetectable. It thus does not reduce the symbolic value of a wedding ring.     

Psychological outcomes affect functional outcomes in patients with severe pelvic ring fractures

PurposeTo evaluate the correlation between post-traumatic functional and psychological outcomes in patients with severe pelvic ring injuries.MethodsForty-four patients who sustained a completely unstable pelvic ring injury (Tile C, AO/OTA 61C) treated in our institution from 2012 to 2017 were included. A telephone interview was performed in 16 of 44 patients to evaluate pelvic functionality, using the Majeed pelvic score, and psychological evaluation, using Hamilton anxiety and depression rating scales.ResultsThe mean Injury Severity Score (ISS) was 27 ± 12, and mean GCS at presentation was 13 ± 4. Average time from trauma to interview was 3 years (range, 1–5 years). Mean Majeed pelvic score was 67 ± 22. Majeed sub-scores were pain 19 ± 9, work 10 ± 7, sitting 8 ± 2, sexual intercourse 3 ± 2, walking aids 11 ± 2, gait unaided 9 ± 2, walking distance 8 ± 3. Mean depression and anxiety scores were 16 ± 12 and 17 ± 14, respectively. Significant correlations were observed between functional and psychological outcomes (P < 0.005). Majeed score was negatively correlated with depressive symptoms (r = -0.721, P = 0.002) and anxiety symptoms (r = -0.756, P = 0.001). Depression and anxiety scores were positively correlated (r = 0.945, P < 0.001).ConclusionLower functional outcomes in patients with Tile C pelvic injuries were correlated with more severe symptoms of depression and anxiety. We recommend that providers consider and treat patients’ mental health condition during posttraumatic recovery.     

A new technique in the management of the ring avulsion injury

There is universal agreement that microvascular repair is the only way to salvage class II ring avulsion injuries. We report on two patients who sustained this type of injury and were treated successfully by extensive fasciotomy. The circulatory compromise following class II ring injuries deteriorates rapidly due to the tourniquet-like effect by the progressive swelling of the soft tissue envelope. Fasciotomy eliminates this effect and allows adequate inspection of the neurovascular bundles. Microvascular repair is still feasible if considered necessary.     

Primary ray resection as an alternative to microsurgical replantation in the management of ring finger avulsion

ObjectivesRay resection of the metacarpal with conservation of the proximal end is a technique of management of complete ring avulsion injuries in the emergency situation. This study is a functional evaluation of the technique in comparison to replantation.MethodsThe present series includes 11 patients, average age of 35 years, predominantly manual workers, operated between October 2005 and July 2007. It consisted of two grades IVA, six grades IVB, and three grades IVC (classification of Merle–Michon). Cases were assessed according to grip and pinch strength, quantitative 400 points score and a work evaluation.ResultsTen patients were evaluated with an average follow-up of nine months (range: three to 19 months). There were no complications apart from four patients with phantom pain. The time to return to work was three months (range: 10–219 days). All patients were satisfied with the cosmetic appearance, however eight of them suffered from psychological problems, finding it difficult to accept a four-fingered hand. Secondary surgery was unnecessary in the majority of the patients (80%). The grip strength was measured as 30% of grip strength of the unaffected side (range: 3–70%). The result of the 400 point score was 75,94% (range: 55–99%).ConclusionRay resection of the metacarpal with conservation of the proximal end is a reliable procedure. Strength is decreased but this does not stand in the way of a rapid return to previous work. However, the choice of strategy (ray resection versus microsurgical replantation) should be discussed in detail with the patient prior to selecting the appropriate option.     

Surgical repair of central slip avulsion injuries with Mitek bone anchor--retrospective analysis of a case series.

The purpose of this study is to describe our technique of central slip repair using the Mitek bone anchor and to evaluate the treatment outcome. Eight digits in eight patients were reconstructed using the bone anchor: three little fingers, two middle fingers, two index fingers and one ring finger. There were two immediate and six delayed repairs (range from one day to eight months). Four patients had pre-operative intensive splinting and physiotherapy to restore passive extension of the proximal interphalangeal joint prior to central slip reconstruction. All patients have made good progress since surgery. No patient requires a second procedure and none of the bone anchors have dislodged or loosened. We conclude that the Mitek bone anchor is a reliable technique to achieve soft tissue to bone fixation in central slip avulsion injuries. We recommend that this technique be considered as a treatment option for patients requiring surgical repair.     

显微外科技术联合置管负压引流技术治疗四肢挤轧逆行撕脱伤的临床研究

目的探讨应用显微外科技术联合置管负压引流技术治疗四肢挤轧逆行撕脱伤的临床效果。方法2016年1月-2019年7月,对20例四肢挤轧逆行撕脱伤采用显微外科技术联合置管负压引流技术进行治疗。结果术后15例撕脱组织完全成活,5例撕脱皮肤近心端小部分坏死(其中3例Ⅱ期植皮愈合,2例结痂愈合)。随访3~12个月,患手外形好,血供充分,皮肤质地柔软。结论应用显微外科技术联合置管负压引流技术治疗四肢挤轧逆行撕脱伤,既能Ⅰ期固定骨折、缝合肌肉肌腱后应用显微外科技术吻接血管、神经,又能通过持续负压引流有效清除渗液,减少毒素再吸收;还可缩小创面,消灭死腔;同时还能改善局部血液循环,减轻或消除水肿,促进肉芽组织生长,加快创面愈合;提高撕脱组织的成活率,减少血管危象的发生;降低四肢挤轧逆行撕脱伤的坏死及伤残率,减少多次手术的痛苦;减轻患者经济负担。是治疗四肢挤轧逆行撕脱伤的好方法。     

Primary vein grafting in treatment of ring avulsion injuries: a 5-year prospective study

Out of 262 hands with total finger amputations treated by replantation of finger/fingers from January 2001 until January 2006, there were only 6 cases of type III ring avulsion injuries, all of which were replanted. Radical resection of the damaged part of the artery with primary vein grafting was used in each case; only 1 artery and 2 veins were anastomosed for each finger. The survival rate was 100%. Mean total active motion was 195 degrees (ranging from 175 degrees to 220 degrees ). Mean 2-point discrimination was 8.6 mm static (ranging from 4 to 11 mm) and 6.2 mm moving (ranging from 3 to 9 mm), and mean grip strength was 37.4 kg. We believe that liberal resection of the "zone of contusion" of vessels and primary vein grafting for arterial repair can improve the overall survival rate of replantation in type III ring avulsion injuries, and replantation can be attempted in majority of the cases; good hand function can be expected.     

Results of ray resection and amputation for ring avulsion injuries at the proximal interphalangeal joint

We investigated the long-term functional results of ray resection (14 cases) and amputation (nine cases) for ring avulsion injuries of ring finger which could not be replanted or underwent failed replantation. The mean follow-up was 37 (range, 24-63) months in the ray resection group and 32 (range, 24-40) months in the amputation group. Grip strength, key pinch strength, chuck pinch strength, hand circumference and palmar volume were decreased in the ray resection group but only grip strength and pulp pinch strength were significantly decreased in the amputation group. These results suggest that ray resection should be avoided in patients with occupations that need strong key and chuck pinch functions.     

Preoperative radiation therapy and its effects on outcomes in microsurgical head and neck reconstruction.

OBJECTIVE: Preoperative radiation therapy is considered a significant factor in head and neck reconstruction. STUDY AND DESIGN AND SETTING: In our consecutive series of 114 patients, 44 patients had prior head and neck irradiation. The 2 groups were compared on the basis of age, ischemic time, and flap size and were found not to be statistically different. The average ischemic time for the irradiated group was 94.1 minutes, and the average was 102.8 minutes for the nonirradiated group. The average flap size for the irradiated group was 69.5 cm 2 and was 72.0 cm 2 for the nonirradiated group. RESULTS: Using a single-factor analysis of variance, the 2 groups did not differ statistically. The overall major flap complication rate for both irradiated and nonirradiated groups was approximately 10%. CONCLUSION: Microvascular reconstruction was accomplished in both irradiated and nonirradiated head and neck patients, with a 99% total flap survival rate and a 10% major flap complication rate.     

Use of a reverse cross-finger flap as a vascularized vein graft carrier in ring avulsion injuries

We describe the use of a reverse cross-finger pedicle flap, previously described by Atasoy, that carries veins used as vascularized grafts to restore venous drainage in ring avulsion injuries. In addition, vascularized soft tissue is provided to cover extensor tendon and exposed bone.     

Our experience with salvage genitourinary fistulae repair: technique and outcomes

Objectives The objectives are to present the long-term results of vaginal reconstructive operations using the labial fat pad flap (Martius flap) interposition. Patients and methods Eight women, 27–65 years old (mean 40), suffering from urinary fistulae (five urethrovaginal and three vesicovaginal) who failed primary repair underwent salvage vaginal reconstruction for damaged urethra or bladder. Urethral or bladder and vaginal defect was closed and a Martius fat flap was interposed between urethra or bladder and vaginal wall flap to secure a watertight separation of the structures. A Martius flap was also used successfully for salvage vaginal reconstruction in three more women, two with extensive injury of their urethra and bladder neck and one with vaginal leakage, after a rectosigmoid neobladder diversion following cystectomy. Results The repair was successful in all eight patients with urinary fistulae and in the one with rectovaginal leakage. The patient with the traumatically injured urethra and bladder neck developed an anastomotic stricture treated with urethral dilatations and internal urethrotomy. The older one developed a vesicovaginal fistula due to bladder neck closure, and this was repaired with a second transvaginal closure. Conclusion Martius labial fat flap is an easy to prepare, well-vascularized tissue that can be most helpful in achieving a long-lasting favorable outcome in vaginal reconstructive surgery.     

Impact of time to repair on outcomes in patients with lower extremity arterial injuries

BackgroundSix hours has long been considered the threshold of ischemia after peripheral artery injury. However, there is a paucity of evidence regarding the impact of operative delays on morbidity and mortality in patients with lower extremity arterial injuries.MethodsWe analyzed the records of 3,441,259 injured patients entered into the National Trauma Data Bank Research Dataset from 2012 to 2015. Patients (≥16 years) with lower extremity arterial injuries were identified by International Classification of Diseases, Ninth Revision injury and procedure codes. Patients with crush injuries, patients with prehospital or emergency department cardiac arrest, those not transferred directly from point of injury, and patients in whom a nonoperative management strategy was attempted were excluded from analysis.ResultsWe examined the data from 4406 patients with lower extremity arterial injuries; 85% of the patients were male, with a mean age of 35 years. The overall mortality in this cohort was 3.2% (143/4406); the amputation rate was 11.3% (499/4406). Using a multivariate logistic regression model, blunt mechanisms of injury, increased time from injury to operating room arrival, nerve injury, associated lower extremity fractures, increased age, and Injury Severity Score were associated with increased amputation risk. The amputation rate in those undergoing repair within 60 minutes was 6% compared with 11.7% and 13.4% in those undergoing repair after 1 to 3 hours and 3 to 6 hours, respectively.ConclusionsOptimal limb salvage is achieved when revascularization of lower extremity arterial injury occurs within 1 hour of injury. To improve survival and recovery after extremity arterial injury, efforts should be focused on strategies to expedite reperfusion of the injured limb.     

Replantation of fingers and hands after avulsion and crush injuries.

INTRODUCTION: Avulsion and crush injuries constitute a particularly difficult problem due to extensive damage of vessels and nerves. In cases where a crush is the dominating injury factor causing complex fractures of forearm and carpal bones, shortening of the extremity is necessary for primary vessel and nerve reconstruction. Surgical experience in vessels dissection and optimal sequence of reconstruction procedures using vessels and nerve grafts are of paramount importance. MATERIAL AND METHODS: In the years 1986-2006 the author carried out 18 replantations and 4 revascularizations at various levels of distal upper limb after crush-avulsion trauma. There were 8 thumb, 7 long fingers and 7 hand amputations. Hand replantations were carried out in 5 males aged 18-45 (mean age 33). Thumb replantations were carried out in 2 females and 5 males. There were 4 complete amputations of a long finger (three teenagers and 32-year-old male). A vein grafting from the forearm was the basic method used in arterial reconstructions (3 hands, 5 thumbs and 6 long fingers). Grafts of the deep radial vein were used in 2 cases (one in hand and one in the thumb). Change in the standard sequence of the replantation procedure (i.e. reconstruction of the artery on the ulnar side of the thumb before bone stabilisation) appeared very helpful on thumb. Rerouting veins, venous flaps or skin flaps from the dorsal surface of the index finger were very useful in reconstruction of the blood outflow. Secondary reconstruction of nerves were carried out in 8 patients (40%) and 5 patients are still waiting for the surgery. RESULTS: Sixteen out of 18 replants (88.9%) and all 4 revascularized parts survived. Overall success rate was 90.9%. CONCLUSIONS: Grafting technique in reconstruction of arteries and veins during the primary vessels repair is a very good method and we advocate that it should be widely used. Due to extent of trauma, majority of the patients required secondary procedures - mainly reconstruction of nerves with nerve grafts.